Medical Form

First(Required)

Middle

Last(Required)

Trip(Required)

Week(Required)

Week One

Week Two

Week Three

Week Four

Gender(Required)

Male

Female

Date of Birth(Required)

Personal Physician(Required)

Physician's Phone Number(Required)

Allergies(Required)

Do you have any physical conditions that might limit your ability to perform the designated work?(Required)

(e.g. not able to climb a ladder, not able to lift heavy objects, not able to get on the roof, etc...)

Medical Conditions(Required)

Operations you have undergone(Required)

(please include the approximate date of the procedure)

Medications you are now taking(Required)

(include dosages)

Agree(Required)

YES, I AGREE to these terms as stated here: --- I hereby grant CWE the use of the above medical information as needed in its discretion to determine my fitness to serve as a volunteer for CWE, as well as in the event that I need first-aid treatment or other medical services rendered in connection with an emergency during my service as a volunteer with CWE.

Date(Required)